LearningMattersEducationalGroupCalibreAcademyofSurprise

15688W.AcomaDr.,Surprise,AZ85379Phone:(623)556-2179Fax:(623)556-2806

¨StudentEnrollmentForms

¨MedicationAdministrationForm

¨ArizonaResidencyForm–(Mustsubmitacopyoftheappropriatedocumentationalongwiththisenrollmentform)

¨HomeLanguageSurvey

¨RaceandEthnicityDataCollectionForm

¨RequestforStudentRecords

¨Directory/PhotoReleaseForm

¨SpecialEducationForm

¨AfterSchoolReleaseForm

¨ParentVolunteerServicesForm

¨StandardofDressForm

¨ComputerInformationServicesUserAgreement

¨GuidelinesToDetermineEligibleStudentsSurvey

¨ImmunizationRecord

¨Student’sProofofIdentityandAge–Thisincludesoneofthefollowing:birthcertificate,student’sbaptismalcertificate,anapplicationforasocialsecuritynumber,aletterfromtheauthorizedrepresentativeofanagencyhavingcustodyofthestudentortheoriginalregistrationrecordsandanaffidavitexplainingtheinabilitytoprovideacopyofthebirthcertificate.

(ForOfficeUseOnly)DatePacketReturned_ _____StartDate________ ______________AssignedTeacher_ _____________

Acceptedby___ _________StaffInitials

DataInputby__ _________StaffInitials

(7/20 v2) 1

Date:_ _____ StudentEnrollmentForm

StudentInformation

FirstName: Middle: LegalLastName:StudentAddress: City: ZIPCode:

Gender:¨Male¨FemaleGrade: HomePhone:DateofBirth: StateofBirth: CountryofBirth:USA Other:

SchoolLastAttended: Address: Phone#:Hasyourchildeverreceivedanyofthefollowing:

SpecialEducationServices¨No¨Yes GiftedServices¨No¨Yes Disciplinary: ¨ Suspension504PlanServices ¨ No¨YesIEP¨No¨Yes ¨ Attendance ¨ Expulsion

Parent/GuardianInformation

CustodyofStudent:¨Joint¨Mother¨Father¨State¨Temporary¨OtherStudentliveswith:¨BothParents¨Mother¨Father¨State¨Temporary¨Other

Mother'sInformation:Contact1st___ Contact2nd___FirstName: LastName: HomePhone:Address: City: State: ZIPCode:PlaceofEmployment: WorkPhone:E-mailAddress: CellPhone:

Father'sInformation:Contact1st___ Contact2nd___FirstName: LastName: HomePhone:Address: City: State: ZIPCode:PlaceofEmployment: WorkPhone:E-mailAddress: CellPhone:

LegalGuardian/OtherInformation: LegalGuardian Step-Parent OtherFirstName: LastName: HomePhone:Address: City: State: ZIPCode:PlaceofEmployment: WorkPhone:E-mailAddress: CellPhone:

SCHOOLUSEONLYDateofEntry: EntryCode: Grade: Teacher: Room:

ImmunizationRecords:¨Yes¨No SAISID#: BirthCertificate:¨Yes¨NoInterview:Scheduledfor: at: PreviousReportCard:¨Yes¨NoInterviewer: Date:

(7/20 v2) 2

Statement of Disclosure

I/We have truthfully answered all questions on this enrollment form.

I/We understand that student grade level placement is based upon his/her previous grades/credits, recommendations, and test

scores.

Please feel free to call or fax the Administration Office if you have any questions.

Signature of Parent/Guardian Date Calibre Academy is a non-sectarian, publicly-funded group of charter schools and does not discriminate in its enrollment or hiring practices on the basis of gender, race, religion, or ethnic origin, color or disability. Signature of Administrator Date

(7/20 v2) 3

MedicationAdministrationFormFromtimetotimestudentsunexpectedlyneedmedicationduringaschoolday.Whenthisneedarises,theschoolnurse(orpersondesignatedbythedirector)mayadministerover-the-countermedications,suchasthoselistedbelow,withparentalconsent.Althoughastudentmayhaveasignedconsentformonfile,whensymptomsariseatschoolofwhichaparentmaynotbeaware,verbal/phoneverificationmaybeobtainedbeforeadministeringmedications.Forstudentsneedingaprescriptionmedicationduringschoolhours,indicatethismedicationanddosagebelow.Ifthedosageand/ormedicationchangesinanyway,immediatelysendawrittenverification,withdoctor’snote,ofthischangetotheoffice.Pleasenotethatitisagainstschoolpolicyforstudentstocarryanyprescriptionorover-the-countermedicationwiththemduringtheschoolday.Thisincludespainrelieversandherbs.Allmedicationmustbecheckedintothefrontofficeandwillbekeptinthehealthspecialist’soffice.Pleasecompletetheformbelow:StudentName:Grade:DateofBirth:

Pleaseliststudent’sallergiesorallergicreactions: Pleaseliststudent’smedicalconditions: Checkeachboxyesorno(ifleftblank,willbeconsideredno)YES NO MEDICATION DOSAGE FREQUENCY

Tylenol(Acetaminophen) Everyfour(4)hoursifnecessary

Advil/Motrin(Ibuprofen) Everyfour(6)hoursifnecessary

Tumsorotherantacids Everyfour(4)hoursifnecessary

Other:Benadryl(Antihistamine)

Other:

PrescriptionMedicine(mustbeinoriginalpharmacybottle/package):

Iauthorizetheschoolhealthspecialistordesigneetogivethemedication(s)checkedabovetomychildwhenneeded.Parent/GuardianSignature:Date:

(7/20 v2) 4

Arizona Department of Education

Arizona Residency Documentation Form

Student__________________________________________ School _________________________ School District or Charter Holder __________________________________ Parent/Legal Guardian ______________________________________________________________ As the Parent/Legal Guardian of the Student, I attest* that I am a resident of the State of Arizona and submit in support of this attestation a copy of the following document that displays my name and residential address or physical description of the property where the student resides:

Valid Arizona driver’s license, Arizona identification card or motor vehicle registration Valid Arizona Address Confidentiality Program authorization card Real estate deed or mortgage documents Property tax bill Residential lease or rental agreement Water, electric, gas, cable, or phone bill Bank or credit card statement W-2 wage statement Payroll stub Certificate of tribal enrollment (506 Form) or other identification issued by a recognized

Indian tribe in Arizona Documentation from a state, tribal or federal government agency (Social Security

Administration, Veteran’s Administration, Arizona Department of Economic Security) Temporary on-base billeting facility (for military families)

I am currently unable to provide any of the foregoing documents. Therefore, I have provided an

original affidavit signed and notarized by an Arizona resident who attests that I have established residence in Arizona with the person signing the affidavit.

____________________________ ______________________ Signature of Parent/Legal Guardian Date

*For members of the armed services, the provision of verifiable documentation does not serve as a declaration of official residency for income tax or other legal purposes. Armed service members may utilize a temporary on-base billeting facility as the address for proof of residency.

(7/20 v2) 5

State of Arizona Affidavit of Shared Residence

Student Name: ___________________________________________________

Parent/Legal Guardian Name: _______________________________________

School Name: ___________________________________________________

School District or Charter Holder: ___________________________________

Name of Arizona Resident: _________________________________________

I, (resident name)___________________________________ swear or affirm that I am a resident of the State of Arizona and that the persons listed below reside with me at my residence, described as follows:

Persons who reside with me: ________________________________________ Location of my residence: __________________________________________

I submit in support of this attestation a copy of the following document that displays my name and current residence address or physical description of my property:

Valid Arizona driver’s license, Arizona identification card or motor vehicle registration Valid Arizona Address Confidentiality Program authorization card Real estate deed or mortgage documents Property tax bill Residential lease or rental agreement Water, electric, gas, cable, or phone bill Bank or credit card statement

W-2 wage statementPayroll stubCertificate of tribal enrollment (506 Form) or other identification issued by a recognized Indian tribein ArizonaDocumentation from a state, tribal or federal government agency (Social Security Administration,Veteran’s Administration, Arizona Department of Economic Security)

Printed Name of Affiant: ________________________________

Signature of Affiant: __________________________________ Acknowledgement

State of Arizona County of _________________________

The foregoing was acknowledged before me this ____ day of___________ , 20____ , By ___________________________________

______________________________ My Commission Expires:

Notary Public ___________________________ (7/20 v2) 6

Home Language Survey

The responses to this Home Language Survey (HLS) are used by the school to provide the most appropriate instructional programs and services for the student. The answers below will determine if a student will take the Arizona English Language Learner Assessment (AZELLA). Please respond to each of the three questions as accurately as possible. If you need to correct any of your responses, this must be done before the student takes the AZELLA Placement Test.

1. What language do people speak in the home most of the time?

_____________________________________________________________

2. What language does the student speak most of the time?

_____________________________________________________________

3. What language did the student first speak or understand?

_____________________________________________________________

Please provide a copy of the Home Language Survey to the EL Coordinator/Main Contact on site. In AzEDS, please enter all three HLS responses.

These HLS questions are in compliance with Arizona Administrative Code (R7-2-306(B)(1),(2)(a-c). (Revised 01-2020)

Student Name________________________________ District Student ID_______________

Date of Birth_________________________________ SSID__________________________

Parent/Guardian Signature______________________________ Date___________________

District or Charter____________________________________________________________

School_____________________________________________________________________

(7/20 v2) 7

RACE and ETHNICITY DATA COLLECTION FORM In accordance with new federal guidance, schools are required to utilize a two-part question to collect data about race and ethnicity. Part 1 is in regards to Ethnicity and Part 2 relates to race. More than one race may now be selected on Part 2.

Date: ______________________ Child’s Name: ______________________________

Parent/Guardian Signature: _________________________________________________

Race/Ethnicity Two-Part Question: Answer BOTH questions.

Part 1: Ethnicity

Is the student Hispanic or Latino? (Choose only one)

No, not Hispanic or Latino

Yes, Hispanic or Latino (A person of Mexican, Puerto Rica, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.

Part 2: Race

What is the student’s race? (Regardless of how respondent answered the first question, choose one or more)

American Indian or Alaska Native (A person having origins in any of the original tribal peoples of North and South America, including Central America, and who maintains affiliation or community attachment.)

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)

Black or African American (A person having origins in any of the black racial groups of Africa.)

Native Hawaiian or Other Pacific islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)

(7/20 v2) 8

StudentRecordsRequest

Iauthorizethereleaseofrecordsforthefollowingstudent:

LastName:______________________________FirstName:___________________________DOB:________

SchoolName/District:____________________________________________LastGradeLevel:____________

Address/City/State/Zip:________________________________________________________________________

Telephone:___________________________________Fax:________________________________________

Pleaseforwardtheentirerecordincluding:

1.BirthCertificate

2.Immunizations/HealthHistory/MedicalEvaluation

3.Attendance

4.IEP/SpecialEdRecords/504Plan

5.PsychologicalEvaluationRecords

6.Grades–OfficialTranscript

7.AchievementScores-Testscores,AZMerit

8.Other______________________________________

Parent/GuardianSignature:_____________________________________Date:__________

PLEASESENDRECORDSTO:

¨ CalibreAcademySurprise1strequest_______________15688W.AcomaDr.Surprise,AZ853792ndrequest_____________Phone:623-556-2179Fax:623-556-2806

(7/20 v2) 9

StudentDirectoryInformationReleaseFormDuringtheschoolyear,schooldistrictorcharterschoolstaffmembersmaycompilenon-confidentialstudentdirectoryinformationspecifiedbelow.Accordingtostateandfederallawthebelow-designateddirectoryinformationmaybepubliclyreleasedtoeducational,occupationalormilitaryrecruitingrepresentativeswithoutyourpermission.Ifthedistrictgoverningboardorcharterschoolgoverningbodypermitsthereleaseofthebelow-designateddirectoryinformationtopersonsororganizationswhoinformstudentsofeducationaloroccupationalopportunities,bylawthedistrictorcharteroperatorisrequiredtoprovidethesameaccessonthesamebasistoofficialmilitaryrecruitingrepresentativesforthepurposeofinformingstudentsofeducationalandoccupationalopportunitiesavailabletothem,unlessyourequestinwritingthattheschoolnotreleasethestudent’sinformationwithoutyourpriorsignedanddatedwrittenconsent.Ifyoudonotobjecttothereleaseofanyandallofthebelow-designatedinformationinwriting,thenthedistrict/charteroperatormustprovidemilitaryrecruiters,uponrequest,directoryinformationcontainingthestudent’snames,addresses,andtelephonelistings.Ifyoudonotwantanyorallofthebelow-designatedinformationaboutyourson/daughtertobereleasedtoanypersonororganizationwithoutyourpriorsignedanddatedwrittenconsent,youmustnotifytheDistrict/charterinwritingbycheckingoffanyoralloftherejectedinformation,signingtheformatthebottomofthispage,andreturningittothePrincipal,withintwo(2)weeksofreceivingthisform,orOctober31,whicheveroccursfirst.Iftheschooldistrictorcharterschooldoesnotreceivethisnotificationfromyouwithintheprescribedtime,itwillbeassumedthatyourpermissionisgiventoreleaseyourson/daughter’sdesignateddirectoryinformation.

--------------------------------------------------------------TO:PrincipalIdonotwantanyoralltheinformationIhaveindicatedbelowconcerning(student’sname)______________________________designatedasdirectoryinformationandreleasedtoanypersonororganizationwithoutmypriorwrittenconsent:

□Name

□TelephoneListing

□Dateandplaceofbirth

□Datesofattendance

□Electronicmailaddress

□Photograph

□Gradelevel

□Honorsandawardsreceived

□Enrollmentstatus(e.g.parttimeorfulltime)

□Address

□Weightandheight(membersofathleticteams)

□Mostrecenteducationalagencyorinstitutionattended

□Majorfieldofstudy

□Participationinofficiallyrecognizedactivities/sports

______________________________________________Parent/GuardianSignatureDate

(7/20 v2) 10

SpecialEducationForm

Inordertoprovidecontinuityinyourchild’seducationalprogram,itisimportantthatCalibreAcademyismadeawareofanySpecialEducationserviceshe/shehasreceived.Pleasecompletethefollowinginformationtohelpusexpediteyourchild’sproperplacement.StudentName:DateofBirth:School:Grade:WasyourChildeverenrolledinanySpecialEducationPrograms?¨Yes¨NoIfyes,pleasespecify:HasyourchildbeentestedorevaluatedforSpecialEducationalServices?*TheEvaluationsmustbeattachedtotheenrollmentpacket.¨Yes¨NoDoesyourchildcurrentlyhaveanIndividualizedEducationPlan(IEP)?*ThecurrentI.E.P.mustbeattachedtotheenrollmentpacket.¨Yes¨NoDoesyourchildcurrentlyhavea504AccommodationPlan?*Thecurrent504AccommodationPlanmustbeattachedtotheenrollmentpacket.¨Yes¨NoHasthestudenteverbeensuspended,dismissed,orexpelledfromaschool?¨Yes¨NoIfyes,pleaseprovidedetails:Iherebycertifythattheaboveinformationistrueandcorrect.Parent/GuardianName(PleasePrint):Parent/GuardianSignature:

(7/20 v2) 11

AfterSchoolDismissalPlan

Toinsurethesafetyofyourchildrenafterschoolreleases,weareaskingforyoutoprovidethefollowinginformation:MyChild,____________________________________will,(checkoneplease)¨ AttendAftercareatCalibre/seefrontofficepersonnelfordetails¨ Walk/Ridebikehome¨ Bepickedupby:______________________________relationship:____________________Contact#____________________________

______________________________relationship:____________________Contact#____________________________

______________________________relationship:____________________Contact#____________________________

AfterSchoolDismissal:Sothatdismissalrunsassmoothlyaspossible,afternoondismissaltimesarestaggeredasfollows:_____2:30PMKindergartenstudentswithoutsiblings*Wednesdayreleasewillbeat12:00forKindergarten.Kindergartenstudentswithsiblingswillbereleasedtothecafeteriatowaitforoldersiblings,releasedasfollows:

• Kindergartenstudentswith1st-3rdgradesiblingswillbepickedupinthesouthparkinglotat2:45P.M.• Kindergartenstudentswith4th-8thgradesiblingswillbepickedupinthesouthparkinglotat3:00P.M.

_____2:45PM1st–2ndgradestudentswithoutoldersiblingsarereleasedfromtheSouthParkinglot.3rdgradestudentswithnosiblingsarereleasedfromtheNorthParkinglot.3rdgradestudentswithayoungersiblingarereleasedfromtheSouthParkinglot.

_____3:00PM4th-8thgradestudentswithoutayoungersiblingarereleasefromtheNorthParkinglot. 4th-8thgradesstudentswitha3rdoryoungersiblingarereleasedfromtheSouthParkinglot.Itisveryimportantthatparentsarriveatthetimeyourstudent(s)aredismissed.Youshouldremaininyourcarsandwewillreleaseyourstudent(s)righttoyou.Pleasedonotleaveyourcarsunattendedorparkinareasotherthandesignatedparkingspaces.Eachfamilywillreceivecoloredplacardswithnumbers.Thesemustbedisplayedinthecarwindshieldorcarriedwithyouinordertopickupyourchildren.EmergencyInformation

EmergencyContactName:Telephone:

RelationshiptoStudent:

EmergencyContactName:Telephone:

RelationshiptoStudent:

Physician'sName:Telephone:

HospitalPreference:

(7/20 v2) 12

VolunteerServicesFormCalibreAcademyencouragesvolunteerassistanceinavarietyofways.CalibreAcademydesiresandneedsvolunteersattheschool.Ifyouareinterestedinvolunteeringinanyoftheareaslistedbelow,pleasechecktheboxthatappliesandcompletethecontactinformationbelow.¨Office

¨ClassroomAide

¨LunchroomAide

¨AthleticEvents

¨FundraisingforClasses

¨PlaygroundAide

¨ParentsClub(Parent/Teacherorganization)

¨Other:

Name:

Address:

Home#: Cell#: Work#:

E-mail:

StudentName(s):Grade(s):

Besttimetocontactyou:

(7/20 v2) 13

DRESS CODE UniformGuidelines CalibreAcademyisauniformschool.AlerttoParents-Ifyourstudentisnotinuniform,youwillreceiveaphonecallfromtheoffice.Ifitisnotpossibleforyoutobringappropriateclothing,yourstudentwillberequiredtowearanappropriatealternativeshirtorslackssuppliedbytheschoolorremainintheofficefortheremainderoftheday.Thedresscodewillbecheckeddailyduringflag/announcements. Pleaselabelalluniformswithablackpermanentmarkerontheinsidecarelabelswithfirstandlastname.AllStudents

1. TheCalibrepoloshirtcolormayonlybelightblue,red,orheathergrayandmusthavetheCalibrelogo.Ifanundershirtisworn,itmustbetuckedinandnotvisiblebelowthehemofthepoloshirt.SpiritshirtsmayonlybewornonFridaysandfieldtrips.

2. Shoes/Socks–GirlsandBoys–Socksandshoesmustbeworneveryday.Girlsmayweartightsorleggingsunderthejumpers,skirts,orskorts.Shoesstylesarethechoiceofstudents,tie-up,flats,etc.;however,opentoedshoes,flipflops,andslippersarenotallowedduetosafetyconcerns.TennisshoesmustbewornonPEdays.

3. Hairstyles–Allstudentsshallkeephairclean,wellgroomed,andconservativeinstyle.Iftherearebangs,theymustnothangbelowtheeyebrows.Boy’shairlengthshouldnotbelongerthantheirearlobesonthesideorbelowthecollarintheback.Boy’shairmaynotbeputupinanywayorforanyreason.Noextremestylesorcolorsareallowed;thisincludesbutisnotlimitedtoMohawks,shavedhairdesigns,andothernon-traditionalhairstyles.Hairmustbeacolorthatwouldnaturallyoccuronanindividual-therewillbenosevereorcontrastinghighlightsofanykind(blue,red,green,pink,etc).StudentsmaynotwearhaircoloronSpiritDays.Theadministrationreservestherighttodecidewhatisacceptableandwhatisnot.

4. Tattoos,bodypiercingotherthanearpiercings,(girlsonly),etc.areunacceptable.Temporarytattoosshouldnotbevisible.5. NoHeeley’sarepermittedoncampus.6. Whenthereisa“wearyourownclothesday”(studentsmayweartheirownclothesontheirbirthdays)clothingmustbeneat,

properfitting,andschoolappropriate.Nointentionalor“stylish”tearsorcutsshouldbefoundonpantsortops.Ifanundershirtisworn,itmustbetuckedinandnotvisiblebelowthehemoftheoutershirt.Noshortorskin-tightshortsorskirtsmaybeworn.T-shirtsmustcovertheentireupperhalfofthebody;nospaghettistrapsortanktops.“DressDown”stillrequirescompliancetothedresscode-shirts,pants/skirts/skorts/shorts,shoes,andsocks.

Note:Toattendclass,allstudentsmustbeincompliancewithallpartsofthestudentdresscode.ItistheresponsibilityofbothparentsandstudentstounderstandandagreetotheCalibredresscodeaspartoftheenrollmentprocess.Girls:Kindergartenthrough8thgradesGirlshavetheoptiontowearthefollowingnavyblue,khakiorbluejeansthatareproperfittinguniformbottoms:pants,shorts,caprisorskortsalongwiththeCalibrelogoshortsleeveorlongsleeveshirt.GirlscanalsowearnavyblueorkhakijumperswithawhitesleevedbuttoneddownshortorCalibrepolo.Shortsmustbewornunderjumpers.Alluniformbottomsmustbenoshorterthantheendofthemiddlefingertipswiththearmstraightattheside.AscheduleofthePEdayswillbesenthomebytheclassroomteacher;tennisshoesmustbewornonthosedays.Jeggings,orleggingsbottomsareallnotallowed.Sweatpantsmaybewornondressdowndaysonly.Boys:Kindergartenthrough8thgradesBoysmaychoosetowearnavyblue,khakiorbluejeansthatareproperfittinguniformpantsorshortsalongwiththeCalibrelogoshortsleeveorlongsleeveshirt.Pantsmustbewornatthewaist.TennisshoesmustbewornonPEdays.Hats-Hatsarenottobeworninsidetheclassrooms.Earpiercing–boysmaynotwearpiercedearrings.

Administrationhastherighttodetermineuniformorhairviolations.

IagreetosupporttheCalibreAcademyStandardofDress.Iunderstandthatviolationsoftheabovedresscodeasperceivedbytheadministrationmayresultindisciplinaryaction.Parent/GuardianName(PleasePrint):

Parent/GuardianSignature:Date:

(7/20 v2) 14

USEOFTECHNOLOGYRESOURCESININSTRUCTIONCOMPUTERINFORMATIONSERVICESUSERAGREEMENT

Detailsofthisuseragreementshallbediscussedwitheachpotentialuserofthecomputerinformationservices.Whenthesignedagreementisreturnedtotheschooland/ordistrictoffice,theusermaybepermittedtousecomputerinformationservices(CIS)resources.Accesstocomputerswillnotbegrantedwithoutaparent/guardiansignatureonthebackofthisform.Student’sinabilitytoaccesscomputerswillaffecttheirgradeinTechnology.TermsandConditionsAcceptableUses.Eachusermust:

• UseoftheCIStosupportpersonaleducationalobjectivesconsistentwiththeeducationalgoalsandobjectivesofLearningMattersEducationGroup.

• Agreenottosubmit,publish,display,orretrieveanydefamatory,inaccurate,abusive,obscene,profane,sexuallyoriented,threatening,raciallyoffensive,orillegalmaterial.

• Immediatelyinformtheirsupervisorifinappropriateinformationismistakenlyaccessed.• Abidebyallcopyrightandtrademarklawsandregulations.• Notrevealhomeaddresses,personalphonenumbersorpersonallyidentifiabledataunlessauthorizedtodosoby

designatedschoolauthorities.• Understandthatelectronicmailordirectelectroniccommunicationisnotprivateandmaybereadandmonitoredby

school-employedpersons.• NotusetheCISinanywaythatwoulddisrupttheuseoftheCISorbyothers.• NotusetheCISforcommercialorfinancialgain,politicallobbying,orfraud.• Notattempttoharm,modify,add,ordestroysoftwareorhardwarenorinterferewithsystemsecurity.• UnderstandthatinappropriateusemayresultincancellationofpermissiontousetheCISandappropriatedisciplinary

actionuptoandincludingexpulsionforstudents.• Publishinformation/studentworkonlyonLMEGserversordistrictapprovedwebhostingvendors.Usersplacing

informationontheInternetusingtheDistrict’sCISarepublishinginformationonbehalfoftheDistrict.• Beresponsiblefortheappropriatestorageandbackupoftheirdata.• Onlydownloadplug-insforthepurposeofenhancingthevisualappealofeducationalwebsites(i.e.Shockwave,RealPlayer,

QuickTime,Flash,etc.).

Inaddition,acceptableuseforDistrictemployeesisextendedtoincluderequirementsto:• MaintainsupervisionofstudentsusingtheCIS.• AgreetodirectlylogonandsupervisetheaccountactivitywhenallowingotherstouseDistrictaccounts.• TakeresponsibilityforassignedpersonalandDistrictaccounts,includingpasswordprotection.• Takeallresponsibleprecautions,includingpasswordmaintenance,file,anddirectoryprotectionmeasures,topreventthe

useofpersonalandDistrictaccountsandfilesbyunauthorizedpersons.

UnacceptableUses.• Usersmaynotconnectorinstallanycomputerhardware,hardwarecomponentsorsoftware,whichistheirown• personalpropertytoand/orinthedistrict’sCISwithoutthepriorapprovaloftheDistrictInformationTechnology• Department.• Usersshallnotpostinformationthatcouldcausedamageorposeadangerofdisruptiontotheoperationsofthe

CISortheDistrict.• Usersshallnotaccessthenetworkforanynon-educationalpurposes.• Userswillnotgainorattempttogainunauthorizedaccesstothefilesofothers,orvandalizethedataorfilesofanother

user.

(7/20 v2) 15

• Userswillnotdownloadandusegames,files,documents,music,orsoftwarefornon-educationalpurposes.(i.e.Shockwavegames/animations,audioandothervisualfiles.)

• Userswillnotpossessanydata,whichmaybeconsideredaviolationoftheseregulations,inpaper,magnetic(disk),oranyotherform.

• Userswillnotdisplaynameorphototopersonallyidentifyanindividualwithoutreceivingwrittenpermission.• Userswillnotrevealfullname,address,phonenumber,orpersonalemailwithoutpermissionfromanadult.• UsersshallnotplagiarizeworksthatarefoundontheInternetoranyotherelectronicresource.• Userswillnotharass,insult,attackothersoruseobscenelanguageinwrittencommunications.• Userswillnotpostanonymousmessages.• Usersmaynotusefreewebbasedemail,messaging,videoconferencing,orchatserviceswithoutwrittenpermissionfrom

LMEGNetworkAdministrator.

ResourceLimitations.• Activitiesthataredeemedbythenetworksupervisortocauseunreasonabledemandonnetworkcapacityordisruptionof

systemoperationareprohibited.• Usersshallsubscribeonlytohighqualitydiscussiongroupsormailingliststhatarerelevanttotheireducationorcareer

development.• UsersshallnotusetheDistrict’sCISforcommercialpurposesorfinancialgain.Thisincludesthecreation,developmentand

offeringofgoodsorservicesforsale,andtheunauthorizedpurchaseofgoodsorservices.DistrictapprovedpurchaseswillbemadefollowingDistrictapprovedprocedures.

• TheDistrict’sportableinformationsystemsandeducationaltechnologyresourcessuchasnotebookcomputers,peripherals,and/orcompaniondevices,willbeattheschoolsitesduringschoolhours.

PersonalResponsibility.YourchildwillreportanymisuseoftheCIStotheadministrationorsystemadministrator,asisappropriate.He/sheunderstandsthatmanyservicesandproductsareavailableforafewandacknowledgetheirpersonalresponsibilityforanyexpensesincurredwithoutDistrictauthorization.NetworkEtiquette.Yourchildisexpectedtoabidebythegenerallyacceptablerulesofnetworketiquette.Therefore,theywill:

• Bepoliteanduseappropriatelanguage.Theywillnotsend,orencourageotherstosend,abusivemessages.• Respectprivacy.Theywillnotrevealanyhomeaddresses,orpersonalphonenumbersorpersonallyidentifiable

information.• Avoiddisruptions.TheywillnotuseCISinanywaythatwoulddisrupttheuseofthesystemsbyothers.• Observethefollowingconsiderations:

o Bebriefo Strivetousecorrectspellingandmakemessageseasytounderstand.o Useshortanddescriptivetitlesforarticles.o Postonlytoknowngroupsorpersons.

ParentorGuardianCosignerAstheparentorguardianofthestudentlistedbelow,Ihavereadthisagreementandunderstandit.IunderstandthatitisimpossiblefortheLearningMattersEducationGrouptorestrictaccesstoallcontroversialmaterials,andIwillnotholdtheDistrictresponsibleformaterialsacquiredbyuseofthecomputerinformationservices(CIS).IalsoagreetoreportanymisuseoftheCIStoaSchoolDistrictadministrator.(Misusemaycomeinmanyformsbutcanbeviewedasmessagessentorreceivedthatindicateorsuggestpornography,unethicalorillegalsolicitation,racism,sexism,inappropriatelanguage,orotherissuesdescribedintheagreement.)Iacceptfullresponsibilityforsupervisionif,andwhen,mychild’suseoftheCISisnotinaschoolsetting.Iherebygivemypermissiontohavemychildusetheelectronicinformationservices.StudentName________________________________________Grade___SchoolYear20to20_LastFirstParentorGuardianName(print)________________________________________________________

ParentSignature_________________________________________________Date________________________

(7/20 v2) 16

Updated June 2020

Guidelines to Determine Eligible Students

The Arizona Department of Education provides the following FY2021 Income Guidelines for Determining Eligibility information for federal funding associated

with programs funder the Elementary and Secondary Education Act (ESEA).

Is your family at or below the current income guidelines based on the attached ESEA Eligibility Guidelines schedule?

Indicator 1 Indicator 2 No

Definition of income: all items such as wages and salaries before any deductions, and other income, such as self-employment, welfare, social security, retirement

benefits, unemployment compensation, worker’s compensation, Aid for Dependent Children, alimony, child support, pensions, insurance or annuity payment,

etc.

If your family qualifies, please complete the following information for each child:

Child’s Name Name of School Grade

_______________________________________ ________________________________________ ______________________________

_______________________________________ ________________________________________ ______________________________

_______________________________________ ________________________________________ ______________________________

_______________________________________ ________________________________________ ______________________________

I hereby certify that all of the above information is true and correct.

Parent/Guardian: ___________________________________ _____________________________________ Date: _________________________ Printed Name Signature

These survey forms should be retained by the school or LEA and kept on file for a period of 5 years.

(7/20 v2) 17

Updated June 2020

ESEA Program Eligibility Guidelines

July 1, 2020 – June 30, 2021

FREE REDUCED

HOW OFTEN INCOME WAS RECEIVED HOW OFTEN INCOME WAS RECEIVED

Family Size: Yearly Monthly 2x Month (Bi-Monthly)

Bi-Weekly (Every Two

Weeks)

Weekly Family Size: Yearly Monthly 2x Month (Bi-Monthly)

Bi-Weekly (Every Two

Weeks)

Weekly

1 $16,588 $1,383 $692 $638 $319 1 $23,606 $1,968 $984 $908 $454

2 $22,412 $1,868 $934 $862 $431 2 $31,894 $2,658 $1,329 $1,227 $614

3 $28,236 $2,353 $1,177 $1,086 $543 3 $40,182 $3,349 $1,675 $1,546 $773

4 $34,060 $2,839 $1,420 $1,310 $655 4 $48,470 $4,040 $2,020 $1,865 $933

5 $39,884 $3,324 $1,662 $1,534 $767 5 $56,758 $4,730 $2,365 $2,183 $1,092

6 $45,708 $3,809 $1,905 $1,758 $879 6 $65,046 $5,421 $2,711 $2,502 $1,251

7 $51,532 $4,295 $2,148 $1,982 $991 7 $73,334 $6,112 $3,056 $2,821 $1,411

8 $57,365 $4,780 $2,390 $2,206 $1,103

8 $81,622 $6,802 $3,401 $3,140 $1,570

Each Additional Member

Add:

$5,824 $486 $243 $224 $112

Each Additional Member

Add:

$8,288 $691 $346 $319 $160

NOTE: If all income is received on the same schedule; Example: alimony = $100/month & pension = $300/month DO NOT use conversion factors

If family reports income sources from more than one schedule; Example: alimony = $100/month & pension = $300/week Income MUST be converted to yearly.

Yearly Income = Monthy x 12 Yearly Income = Twice Per Month (Bi-Monthly) X24 Yearly Income = Every Two Weeks (Bi-Weekly) x26 Yearly Income = Week X52 DO NOT round the value resulting from each conversion

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CalibreBusTransportation*

Student’sName:______________________________________________GradeLevel:_________Pleasecheckoneoftheappropriateboxes.¨ No,Idonotneedtohavetransportationformychild ¨ Yes,Iwouldliketohavebustransportationformychild.Ifyes,pleaseprovideyourcontactinformation.Mymajorcrossstreetsare:________________________________________________________________________Name: Address:________________________________________________________________________ContactPhoneNumber:________________________________________________________________________Pleasereturncompletedformtotheschool’smainoffice.Thankyou!*Pleasenote:Ourbusonlyservicesalimitedarea.Pleasecontacttheofficeforfurtherdetails.

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ChildFindCalibreAcademySchoolswillidentify,locateandevaluateallchildrenwithdisabilitieswithintheirpopulationservedwhoareinneedofspecialeducationandrelatedservices.InitsidentificationprocessCalibreAcademySchoolswillincludechildrenwhoaresuspectedofbeingachildwithadisabilityandinneedofspecialeducation,eventhoughastudentis:•Advancingfromgradetograde•Highlymobile,includingamigrantstudent.[34C.F.R.300.111]CalibreAcademySchoolswillinformthegeneralpublicandparentswithinitspopulationservedoftheresponsibilityforthespecialeducationservicesforstudentsagedthree(3)throughtwenty-one(21)years,andhowthoseservicesmaybeaccessedincludinginformationregardingearlyinterventionservicesforchildrenagedbirththroughtwo(2)years.Servicesforaneligiblestudentwithadisabilityshallextendthroughconclusionoftheinstructionalyearduringwhichthestudentattainstheageoftwenty-two(22).[A.A.C.R7-2-401.C]CalibreAcademySchoolswillrequireallstaffmemberstoreviewthewrittenproceduresrelatedtochildidentificationandreferralonanannualbasis,andmaintaindocumentationofthestaffreview.[A.A.C.R7-2-401.D]Identificationscreeningforpossibledisabilitiesshallbecompletedwithinforty-five(45)calendardaysafter:•Entryofeachpreschoolorkindergartenstudentandanystudentenrollingwithoutappropriaterecordsorscreening,evaluation,andprogressinschool;or•Parentnotificationofdevelopmentaloreducationalconcerns.Screeningproceduresshallincludevisionandhearingstatusandconsiderationofthefollowingareas:•Cognitiveoracademic;•Communication;•Motor;•Socialorbehavioral;and•Adaptivedevelopment.

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Arizona Immunization Program Office • 150 North 18th Avenue, Suite 120 Phoenix, AZ 85007 • (602) 364-3630

Last revision: September 2018

GUIDE TO ARIZONA IMMUNIZATIONS REQUIRED FOR SCHOOL ENTRY

GRADES K-12

Immunization requirements by age and grade for school attendance. Vaccines must follow minimum intervals and ages to be valid. A 4-day grace period applies in most situations.

Vaccine

4-6 Years Old Kindergarten or 1st grade

7-10 Years Old 11 Years and Older

Hepatitis B (Hep B or HBV)

3 doses 3 doses acceptable if dose #3 was received at or after 24 weeks of age; otherwise 4 doses are required with the final dose at or after 24 weeks of age.

Poliomyelitis/ Polio (IPV or OPV)

4 doses 3 doses acceptable if dose #3 was received on or after 4 years of age. Students who received 3 or 4 doses (with 4 weeks minimum intervals between doses) PRIOR to August 7, 2009 have met the requirement. The final dose of polio administered ON or AFTER August 7, 2009 must be given at a minimum of 4 years of age AND a minimum interval of 6 months following the previous dose. Polio is not required for students who are 18 years of age or older.

Measles, Mumps and Rubella (MMR or MMR-V)

2 doses A 3rd dose will be required if dose #1 was given more than 4 days before 1st birthday MMR and Varicella must be given on the same day or at least 28 days apart

Varicella (chickenpox) (VAR or MMR-V)

1 dose 2 doses are required if the 1st dose was given at 13 years of age or older.

MMR and Varicella must be given on the same day or at least 28 days apart

Diphtheria, Tetanus, and Pertussis

5 doses of DTaP, DTP or DT 4 doses acceptable if last dose was given on or after 4 years of age. A 6th dose is required if 5 doses have been given before 4 years of age.

4 doses of DTaP, DTP, DT, Tdap or Td 3 doses acceptable if first dose was given on or after 1st birthday. Tdap given at ages 7-10 will meet the 11-year-old+ Tdap requirement.

1 dose of Tdap is required Students must have a minimum of 3 doses of tetanus/diphtheria vaccine which may include 1 Tdap. If Tdap has not been previously given, 1 dose of Tdap is required when at least 5 years has passed since the last dose of tetanus-containing vaccine.

Quadrivalent Meningococcal (MenACWY or MCV4)

1 dose of quadrivalent meningococcal ACWY is required. A dose administered at 10 years of age will meet the requirement.

Please see reverse for additional information and exceptions and conditions to the rules.

(7/20 v2) 21

Rev. 519V3

2020-2021

McKinney - Vento Program - Intake Form

Please Print Clearly in the boxes below:

Student Name: Date of Birth:

Name Student # Grade Age School (if not enrolled, please indicate)

1. Where are you and your family currently staying?

Section A:

Rent/Own my own home

STOP: IF YOU HAVE MARKED THAT YOU OWN/RENT YOUR OWN HOME,

SIGN UNDER ITEM 2 AND SUBMIT FORM TO SCHOOL PERSONNEL.

Explanations listed below: 1Sharing the housing of other persons due to loss of housing, economic hardship, or similar reason

2Living in a car, park, campsite, trailer park, bus/train station, abandoned building, abandoned hospital, or other location

not ordinarily used as sleeping accommodations.

Is your current residence a temporary living situation? Yes No

Is your living arrangement due to the loss of housing or economic hardship? Yes No

Please check the following services that are needed/desired:

School Supplies Clothing/Uniform Free Lunch Gifted/Talented

Visual Referral Tutoring Special Education

Missing Enrollment Records

_____ Birth Certificate _____ Prior Academic Records

_____ Immunization/Medical Records _____ Guardianship Issues

2. The undersigned certifies that the information provided above is accurate.

__________________________________________________________________________________________________ Print Parent/Guardian Name/Adult Caring for Student Signature Date (Must be after 7/1)

____________________________________________________________________________________________ (Area Code) Phone Number Street Address City State Zip Code

For School Use Only

Free/Reduced Guidelines to Determine Eligible Students Signed/Submitted Referred Form to Liaison

__________________________________________________________________________________________________

Print School Contact Title Signature (required) Date

Please list siblings or other children in the home:

Section B:

Shelter Doubled Up1 Hotel/Motel Unsheltered

2

Other:______________________________

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